Select Page

In the aftermath of terrorist attacks or genocide, there are often more survivors than fatalities. Survivors may experience a variety of trauma symptoms, including intense fear, crippling grief, guilt, disorientation, and rage. In addition, survivors may be at risk for developing psychological disorders, such as depression and PTSD. There is often a marked variation in the way in which survivors react to terrorism and genocide, depending on factors such as proximity to the traumatic event, intensity of trauma symptoms following the event, and personal coping strategies previously employed by the survivors. The variation of survivors’ reactions demands that crisis workers be flexible in how they choose and apply crisis intervention strategies. In order to choose an appropriate crisis intervention strategy, crisis workers first must assess and evaluate the affective, behavioral, and cognitive impact to survivors and the larger ecological impact to communities. Then, based on the assessment, an appropriate intervention strategy can be chosen.To prepare for this Assignment:Identify two accounts of terrorism and/or genocide from this week’s readings and consider the affective, behavioral, cognitive, and ecological impact of each.Review the assigned readings and consider strategies and/or skills you might use to respond to survivors of the accounts of terrorism and/or genocide that you identified.The Assignment: (2–3 pages). .Analyze the traumatic impact (e.g., affective, behavioral, cognitive, and ecological) of two different acts of terrorism and/or genocide from this week’s readings.Explain how you might respond to each account of terrorism and/or genocide. In your explanation, be sure to include brief descriptions of the crisis intervention strategies and/or skills you might use to respond to survivors and explain why you chose them.Support your Assignment with specific references to all resources used in its preparation.
mental__and_physical_health_effects_of_acute_exposure.pdf

mental_health_of_somali_adolescent_refugees.pdf

anticipated_attitudes_for_providing_psychological_services.pdf

assessment_a_developmenta_eco_perspective.pdf

Unformatted Attachment Preview

460406
research-article2013
PSSXXX10.1177/0956797612460406Silver et al.Media Exposure to Collective Trauma
Research Article
Mental- and Physical-Health Effects of
Acute Exposure to Media Images of the
September 11, 2001, Attacks and
the Iraq War
Psychological Science
24(9) 1623­–1634
© The Author(s) 2013
Reprints and permissions:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0956797612460406
pss.sagepub.com
Roxane Cohen Silver1, E. Alison Holman2, Judith Pizarro Andersen3,
Michael Poulin4, Daniel N. McIntosh5, and Virginia Gil-Rivas6
1
Department of Psychology and Social Behavior, University of California, Irvine; 2Program in Nursing Science,
University of California, Irvine; 3Department of Psychology, University of Toronto-Mississauga; 4Department of
Psychology, University at Buffalo; 5Department of Psychology, University of Denver; and 6Department of
Psychology, University of North Carolina, Charlotte
Abstract
Millions of people witnessed early, repeated television coverage of the September 11 (9/11), 2001, terrorist attacks and
were subsequently exposed to graphic media images of the Iraq War. In the present study, we examined psychologicaland physical-health impacts of exposure to these collective traumas. A U.S. national sample (N = 2,189) completed
Web-based surveys 1 to 3 weeks after 9/11; a subsample (n = 1,322) also completed surveys at the initiation of the
Iraq War. These surveys measured media exposure and acute stress responses. Posttraumatic stress symptoms related
to 9/11 and physician-diagnosed health ailments were assessed annually for 3 years. Early 9/11- and Iraq War–related
television exposure and frequency of exposure to war images predicted increased posttraumatic stress symptoms 2 to
3 years after 9/11. Exposure to 4 or more hr daily of early 9/11-related television and cumulative acute stress predicted
increased incidence of health ailments 2 to 3 years later. These findings suggest that exposure to graphic media images
may result in physical and psychological effects previously assumed to require direct trauma exposure.
Keywords
September 11, Iraq War, terrorism, media, television, acute stress symptoms, posttraumatic stress symptoms, physical
health
Received 1/26/12; Revision accepted 8/14/12
Mass media turn local disasters into national and global
events. This widespread exposure generates an outpouring of philanthropy (Chochinov, 2005). But the media also
transmits the negative impact of disasters to people far
beyond those directly exposed (Vasterman, Yzermans, &
Dirkzwager, 2005; Wright, Ursano, Bartone, & Ingraham,
1990). In such cases, vicariously experienced events can
become collective traumas. For example, although tens of
thousands of individuals directly witnessed the September
11 (9/11), 2001, terrorist attacks, millions more viewed the
attacks and their aftermath via the media. Indeed, a survey conducted in 2012 found 9/11 to be the most impactful event experienced by television viewers over the past
50 years, almost twice as impactful as the second-ranked
event (Bauder, 2012). When war was initiated in Iraq 18
months after 9/11, international media provided unprecedented graphic images of hostilities.
The potentially detrimental mental-health impact of
media exposure to violence or disasters has concerned
many commentators. Research conducted among children after the Oklahoma City bombing (Pfefferbaum
et al., 2001) and the 1990 Gulf War (Cantor, Mares, &
Corresponding Author:
Roxane Cohen Silver, Department of Psychology and Social Behavior,
4201 Social & Behavioral Sciences Gateway, University of California,
Irvine, CA 92697-7085
E-mail: rsilver@uci.edu
Silver et al.
1624
Oliver, 1993) found relations between television exposure and trauma-related symptoms. Television exposure
to 9/11 and psychological symptomatology were associated in cross-sectional studies among New York residents
(Ahern et al., 2002; Bernstein et al., 2007) and in U.S.
national samples (Butler et al., 2009; Schlenger et al.,
2002; Schuster et al., 2001). The impact of 9/11 even
crossed the Atlantic: London schoolchildren who witnessed the attacks on television reported posttraumatic
stress symptoms and functional impairment during the 6
months following 9/11 (Holmes, Creswell, & O’Connor,
2007), and authors speculated that the observed decline
in subjective well-being in the United Kingdom after 9/11
resulted from extensive worldwide media coverage of
the attacks (Metcalfe, Powdthavee, & Dolan, 2011).
Exposure to traumatic events may affect physical as
well as mental health (Schnurr & Green, 2004), even
among individuals indirectly exposed to collective stressors (Holman et al., 2008; Shedd et al., 2004). Among
women who were pregnant during 9/11, population
studies documented deleterious birth outcomes across
the United States (Bruckner, Catalano, & Ahern, 2010)
and The Netherlands (Smits, Krabbendam, de Bie, Essed,
& van Os, 2006), and Iraq War media coverage predicted
harmful physical- (and mental-) health outcomes among
a sample of Iraqi refugees in the United States (Kira et al.,
2008).
Researchers have emphasized the need for longitudinal examination of the media’s role—and of graphic
images specifically—in mental-health outcomes following traumatic events (Cantor, 2002; Putnam, 2002;
Vasterman et al., 2005). Although experimental research
has demonstrated that exposure to traumatic film images
can induce intrusive emotional memories (Holmes &
Bourne, 2008), the extant body of cross-sectional data
collected outside the laboratory cannot clarify whether
distress increases exposure or vice versa. Only prospective longitudinal studies can begin teasing apart the
direction of this relationship. We speculate that repeated
exposure to vivid traumatic images in the media may
result in a stress response (Bovin & Marx, 2011) sufficient
to trigger physiological processes that increase the risk of
developing health ailments over time (McEwen, 1998;
Schnurr & Green, 2004)—physiological processes distinct
from the known associations between media exposure
and health-risk factors, such as a sedentary lifestyle and
poor dietary choices (Hancox, Milne, & Poulton, 2004).
We conducted a 3-year longitudinal study of mentaland physical-health outcomes among a national probability sample of Americans primarily exposed to the 9/11
attacks through the media. Our study included assessments of respondents’ mental- and physical-health history collected before the attacks, media exposure, and
acute stress responses collected immediately after 9/11
and at the initiation of the Iraq War, and three annual
follow-up assessments. We hypothesized that repeated
exposure to graphic media content would be associated
with increased acute stress symptoms, subsequent posttraumatic stress, and physical-health ailments over time,
controlling for potential confounds (demographics, pre9/11 mental and physical health, and lifetime adversity).
We also examined whether repeated media exposure to
collective traumas has a cumulative effect on health.
Method
Sample and procedures
Data were collected via Internet-based surveys using a
sample drawn from a national probability panel of the
U.S. population recruited using stratified random-digitdial telephone sampling and maintained by Knowledge
Networks (Silver, Holman, McIntosh, Poulin, & Gil-Rivas,
2002; Silver et al., 2006). To ensure representation of all
population segments, Knowledge Networks provides
Internet access, or other compensation (e.g., points for
merchandise) if the household is already Web enabled, in
return for the completion of 3 to 4 monthly surveys. The
panel follows the distribution of U.S. Census population
counts on demographic variables. Survey responses are
confidential, with identifying information never revealed
by Knowledge Networks. Panel members receive notice
in their password-protected e-mail account that a survey
is available for completion. Surveys are self-administered,
accessible for a designated period, and can be completed
only once.
Media exposure and acute stress symptoms were
assessed 9 to 14 days after 9/11 for the majority of the
sample and 8 to 18 days after the Iraq War began for the
entire sample. Self-reports of physician-diagnosed mental
and physical ailments were assessed before 9/11 and 1,
2, and 3 years after 9/11. Posttraumatic stress symptoms
related to 9/11 were also assessed 1, 2, and 3 years after
9/11. The study design and dates of survey administrations are described in Table 1. The survey administered
in the weeks following the 9/11 attacks was fielded to
3,496 individuals; 78% completed it (n = 2,729), with
more than 75% doing so within 9 to 14 days after the
attacks. For each annual follow-up, responses were
obtained only from available respondents from the original sample of 2,729 (some respondents had died or left
the Knowledge Networks panel and declined further participation). For the Year 1 follow-up survey, responses
were received from 2,033 individuals out of 2,729 who
were contacted (74.5%). For the Year 2 follow-up survey,
responses were received from 1,571 individuals out of
2,123 who were contacted (74%, or 57.6% of the original
sample of 2,729). For the Year 3 follow-up survey,
Media Exposure to Collective Trauma
1625
Table 1. Study Design: Measures Collected at Each Time Point of the Study
Measure
Acute stress
Media exposure
Physician-diagnosed
mental health
Physician-diagnosed
physical health
Posttraumatic stress
symptoms
Pre-9/11
survey
(N = 2,592)
September
2001 Post-9/11
survey
(N = 2,729)
September–
October 2002
Annual Survey:
Year 1
(N = 2,033)
March 2003
Iraq War
Survey
(N = 1,349)
September–
October 2003
Annual Survey:
Year 2
(N = 1,571)
September–
October
2004 Annual
Survey: Year 3
(N = 1,771)


X
X
X


X
X
X
X



X


X
X

X

X
X


X

X
X
Note: Prior to September 11 (9/11), 2001, Knowledge Networks administered a health survey. Responses to the post-9/11 survey were obtained
between September 20 and October 4, 2001. Data for the Year 1 post-9/11 follow-up survey were collected between September 20 and October
24, 2002. Data for the Year 2 post-9/11 follow-up survey were collected between September 12 and October 31, 2003. Data for the Year 3 post9/11 follow-up survey were collected between September 12 and November 2, 2004. The Iraq War survey was fielded between March 27 and
April 6, 2003.
responses were received from 1,771 individuals out of
the 2,242 who were contacted (79%, or 64.9% of the original 2,729). Data for the Iraq War survey were collected
over 10 days from a random subset (n = 1,800) of the
respondents from the Year 1 follow-up survey. All procedures for this study were approved by the institutional
review boards of the University of California, Irvine, and
the University of Denver.
Measures
Demographics. Age, sex, marital status, ethnicity, education, and annual household income were provided by
Knowledge Networks. Missing income values were
imputed using a mean income score for the respondent’s
census block.
Direct exposure to the 9/11 attacks. On recruitment
into our study, participants were asked about their degree
of exposure to and loss from the 9/11 attacks. Individuals
were grouped into three mutually exclusive categories
(with priority placed on the highest level of exposure
reported). The first category was direct exposure—being
in the World Trade Center or Pentagon during the attacks,
seeing or hearing the attacks in person, or having a close
relationship with someone in the targeted buildings or
airplanes. The second category was live media exposure—watching the attacks live on television. The third
category was no live exposure—seeing or learning of the
attacks only after they occurred.
Media exposure to the 9/11 attacks. Media exposure
to the 9/11 attacks was assessed at the first wave of data
collection with the following question: “Since the terrorist
attack, about how much time each day have you spent
watching news footage about this on TV? Please give
your best estimate for the first seven days after the attack.”
A categorical variable was used (less than 1 hr per day, 1
to 3 hr per day, and 4 or more hr per day).
Media exposure to the Iraq War. Media exposure to
the Iraq War was assessed starting a week after the Iraq
War began by asking respondents to indicate on a 5-point
scale how frequently they had seen 16 progressively
aversive war images (e.g., military equipment, bombs
exploding, injured/dead soldiers). These items were
modeled after items on the Escobar Combat Intensity
Scale (Escobar et al., 1983). The mean of these items
served as an index of war-related media exposure. Scale
items were also analyzed individually to identify the specific images associated with outcomes. In addition,
respondents provided the average number of hours per
day they spent watching war-related television coverage.
These items were coded similarly to the items related to
9/11-related television watching (less than 1 hr per day, 1
to 3 hr per day, and 4 or more hr per day).
Acute stress responses to the 9/11 attacks and the
Iraq War. Acute stress symptoms were assessed after
9/11 using a modified version of the Stanford Acute Stress
Reaction Questionnaire (SASRQ), which measures symptoms of acute stress disorder (ASD; see Cardena, Koopman, Classen, Waelde, & Spiegel, 2000, for reliability and
validity information). Respondents reported whether they
experienced or did not experience stress symptoms
related to 9/11. Following criteria from the fourth edition
Silver et al.
1626
of the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV; American Psychiatric Association, 1994),
we created two scores—mean acute stress symptoms
and high versus low acute stress—using ASD Criteria B
(three or more dissociative symptoms), C (one or more
reexperiencing/intrusive symptoms), D (one or more
avoidance symptoms), and E (one or more arousal/anxiety symptoms); respondents meeting all four criteria
were coded as having high acute stress. Because most
respondents did not meet DSM–IV Criterion A (direct
exposure) and symptom duration was not assessed,
respondents were not assumed to have ASD. Acute stress
responses to the Iraq War were assessed using the original SASRQ focused specifically on reactions to the war.
Items were classified so that symptoms experienced at
least “sometimes” on the 6-point scale were considered
positive. Continuous and dichotomous acute-stress indices were computed as described above. A cumulative
index of collective acute stress was created from the
dichotomous 9/11-related and Iraq War–related acutestress scores (0 = never had high acute stress, 1 = had
high acute stress after either 9/11 or the beginning of the
Iraq War, 2 = had high acute stress after both events).
(e.g., asthma, hypertension) or mental-health ailments
(i.e., anxiety disorder, depression) and provided smoking
status, height, and weight (to calculate body mass index,
or BMI). The number of pre-9/11 physician-diagnosed
physical-health ailments (0–33) and mental-health ailments (0–2) were computed as baseline assessments.
Three follow-up health surveys, patterned after the pre9/11 assessment, were administered to all available
respondents annually (Holman et al., 2008). Missing-atrandom tests for physician-diagnosed ailments were nonsignificant (ps > .10), so missing data were imputed within
age groups using expectation-maximization methods (Little & Rubin, 1987). Respondents’ tendency to somatize
was also assessed annually using the Brief Symptom
Inventory 18 somatization subscale (Derogatis, 2001).
Posttraumatic stress symptoms related to 9/11. The
PTSD Checklist Civilian (PCL-C), a reliable 17-item screening tool for posttraumatic stress disorder (PTSD), was
administered annually to assess prior-week 9/11-related
symptoms of posttraumatic stress (see Weathers, Litz, Herman, Huska, & Keane, 1993, for reliability and validity
information). A standardized mean score and dichotomous index of high versus low posttraumatic stress using
DSM–IV PTSD Criteria B (one or more reexperiencing
symptoms), C (three or more avoidance symptoms), and
D (two or more arousal symptoms) were created. For
dichotomous scores, only symptoms that were reported
as being at least moderately distressing were considered
positive (i.e., 2 on a scale from 0 to 4); respondents meeting all three criteria were coded as having high posttraumatic stress. Because we did not assess all DSM–IV criteria
(e.g., duration of symptoms) and most respondents were
not directly exposed, they were not assumed to have
PTSD.
The base sample for this report included respondents
with 9/11-related exposure and acute stress data (N =
2,189). The analysis predicting 9/11-related acute stress
used this full sample. As all subsequent analyses included
data from the Iraq War survey, only Iraq War–survey
respondents with 9/11-related exposure and acute-stress
data (n = 1,322) were used.
Stata data analysis and statistical software (Version
10.0; StataCorp, College Station, TX), which handles
weighted complex longitudinal survey data and provides
necessary standard-error adjustments, was used for analyses. Data were weighted to adjust for differences in probabilities of selection and nonresponse. Poststratification
weights were calculated using demographic combinations
to make the weighted sample cells match the data from
the U.S. census (U.S. Census Bureau, 2001) and Knowledge
Networks panel.
Predictors of low versus high acute stress following
9/11 and the initiation of the Iraq War were examined
with survey logistic regression. We used separate survey
linear and Poisson regressions to examine media variables as predictors of posttraumatic stress and physicalhealth ailments at 2 and 3 years after 9/11, controlling for
pre-9/11 health. Generalized estimating equations (GEEs)
were then used to test predictors of posttraumatic-stress
scores and physician-diagnosed physical ailments in multivariate models over time (2–3 years after 9/11). GEE
explicitly models the contribution of time to longitudinal
outcomes and minimizes the number of tests conducted,
thereby strengthening our confidence in estimating the
Pre- and post-9/11 physical- and mental-health status. Prior to 9/11, Knowledge Networks administered a
health survey assessing physician-diagnosed mental- and
physical-health ailments. This survey was modeled after
and validated against the U.S. Centers for Disease Control
and Prevention’s National Center for Health Statistics
annual National Health Interview Survey (NHIS; U.S.
Department of Health and Human Services, 2000).
Respondents reported whether a physician had ever
diagnosed them with any of 35 physical-health ailments
Adverse life events. At the time of recruitment and
annually, participants reported whether they had experienced any of 37 stressful events (other than 9/11; e.g.,
physical assault). The number of lifetime and post-9/11
adverse events was computed.
Overview of analyses
Media Exposure to Collective Trauma
unique contribution of media viewing. Temporally separate assessments of predictors (before 9/11, 2–3 weeks
after 9/11, 12 and 18 months after 9/11) and outcomes
(2–3 years after 9/11) prevented confounding from simultaneous measurement. This allowed prospective evaluation of 9/11- and Iraq War–related media exposure and
cumulative event-related acute stress in relation to the
onset of posttraumatic stress symptoms and health ailments. Analyses were repeated using continuous mean
acute stress symptoms reported after 9/11 and the Iraq
War; findings were consistent with those reported here.
Individual regression and GEE analyses produced similar
findings unless indicated.
Because the rates of meeting DSM–IV PTSD-related
Criteria B, C, and D were minimal (< 5% of the sampl ... Purchase answer to see full attachment